How much opioid analgesia do pediatric patients need after closed reduction and percutaneous pinning of a supracondylar humeral fracture? Not as much as they are being prescribed, suggests a study of 81 kids (mean age of 6 years) by Nelson et al. in the January 16, 2019 issue of The Journal of Bone & Joint Surgery.
All patients in the study underwent closed reduction and percutaneous pinning at a single pediatric trauma center. The authors collected opioid utilization data and pain scores (using the Wong-Baker FACES scale) for postoperative days 1 to 7, 10, 14, and 21 via a text-message system, with automated text queries sent to the phones of the parents/guardians of the patients. (Click here for another January 16, 2019 JBJS study that relied on text messaging.)
Not surprisingly, the mean postoperative pain ratings were highest on the morning of postoperative day 1, but even those were only 3.5 out of a possible 10. By postop day 3, the mean pain rating decreased to <2. As you’d expect, postoperative opioid use decreased in parallel to reported pain.
Overall, patients used only 24% of the opioids they were prescribed after surgery. (See related OrthoBuzz post about the discrepancy between opioids prescribed and their actual use by patients.) Considering that pain levels and opioid usage decreased in this patient population to clinically unimportant levels by postoperative day 3, the authors conclude that “opioid prescriptions containing only 7 doses would be sufficient for the majority of [pediatric] patients after closed reduction and percutaneous pinning without compromising analgesia.”
Now that some normative data such as these are available, Nelson et al. “encourage orthopaedic surgeons treating these common [pediatric] injuries to reflect on their opioid-prescribing practices.” They also call for prospective randomized studies into whether non-narcotic analgesia might be as effective as opioid analgesia for these patients.
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings cited in the February 17, 2016 Specialty Update on pediatric orthopaedics:
Guidelines and AUCs
–The AAOS updated its clinical practice guidelines on the treatment of pediatric diaphyseal femoral fractures1 and adopted appropriate use criteria (AUC) for pediatric supracondylar humeral fractures with vascular injury.2
–A matched case control study of surgical spinal procedures found that neuromuscular scoliosis, weight for age ≥95th percentile, ASA score of ≥3, and prolonged operative time were associated with a higher risk of surgical site infection.3
–Several groups, including the Scoliosis Research Society and POSNA, endorsed the definition of early-onset scoliosis as “scoliosis with onset less than the age of ten years, regardless of etiology.”4, 5
–A prospective randomized study found that preoperative education and orientation for scoliosis surgery paradoxically increased immediate postoperative anxiety among patients and caregivers, relative to controls who received standard perioperative information.6
–A randomized trial investigating perioperative blood loss and transfusion rates in patients undergoing posterior spinal arthrodesis for adolescent idiopathic scoliosis found that tranexamic acid and epsilon-aminocaproic acid reduced operative blood loss but not transfusion rates when compared with placebo.
–A study of 30 patients with severe stable slipped capital femoral epiphysis found that good or excellent results were achieved over 2.5 years in a higher proportion of those receiving a modified Dunn realignment compared with those treated with in situ fixation. The reoperation rate was greater in the in situ fixation cohort.7
–A prospective study analyzing complications after periacetabular osteotomy for acetabular dysplasia using the modified Clavien-Dindo grading scheme found grade III or IV complications in 5.9% of 205 patients, with a nonsignificant trend associating complications with male sex and obesity.
–A registry-based study found that, compared with matched controls, patients with Legg-Calve-Perthes disease had an elevated hazard ratio of 1.5 for ADHD, 1.3 for depression, and 1.2 for mortality. It remains unclear whether patients with Legg-Calve-Perthes disease would benefit from routine psychiatric screening.8
–A case control study of 822 injured athletes and 368 uninjured athletes found that overuse injuries represented 67.4% of all injuries. The risk of serious overuse injury was two times greater if the weekly hours of sports participation were greater than the athlete’s age in years.9
–A meta-analysis of initial nonoperative treatment compared with operative treatment of ACL tears in children and adolescents noted instability and pathologic laxity in 75% of patients with nonoperative treatment compared with 14% of patients following reconstruction.10
–A review of more than 4,400 supracondylar humeral fractures with isolated anterior interossesous nerve palsies but without sensory nerve injury or dysvasculartity found that postponing treatment for up to 24 hours did not delay neurologic recovery.
–A randomized controlled trial investigating the effectiveness of analgesics during intraossesous pin removal found that acetaminophen and ibuprofen were clinically equivalent to placebo in terms of pain reduction and heart rate.
Foot and Ankle
–A study exploring risk factors for failure of allograft bone after calcaneal lengthening osteotomy found a lower risk of failure with tricortical iliac crest allograft relative to patellar allograft. The risk of radiographic graft failure increased with patient age.11
–A prospective nonrandomized study of symptomatic planovalgus feet comparing subtalar arthroereisis with lateral column lengthening found similar postoperative improvements and complication rates in both groups after one year.12
Musculoskeletal Infection & Neuromuscular Conditions
–A cohort study of 869 children with osteomyelitis, septic arthritis, pyomyositis, or abscess concluded that routinely culturing for anaerobic, fungal, and acid-fast bacterial organisms is not recommended except in patients with a history of penetrating injury, immunocompromise, or failure of primary treatment.
–A prospective study comparing tendon transfers, botulinum toxin injections, and ongoing therapy in children with upper-extremity cerebral palsy found that tendon transfer demonstrated greater improvements than the alternatives in joint positioning during functional tasks and grip and pinch strength.
- American Academy of Orthopaedic Surgeons.Guideline on the treatment of pediatric diaphyseal femur fractures. 2015.http://www.aaos.org/Research/guidelines/PDFFguideline.asp.
- American Academy of Orthopaedic Surgeons.Appropriate use criteria: pediatric supracondylar humerus fractures with vascular injury. 2015.http://www.aaos.org/research/Appropriate_Use/pshfaucvascular.asp.
- Croft LD, Pottinger JM, Chiang HY, Ziebold CS, Weinstein SL, Herwaldt LA. Risk factors for surgical site infections after pediatric spine operations. Spine (Phila Pa 1976). 2015 Jan 15;40(2):E112-9
- El-Hawary R, Akbarnia BA. Early onset scoliosis – time for consensus. Spine Deformity. 2015 Mar;3(2):105-6
- Skaggs DL, Guillaume T, El-Hawary R, Emans J, Mendelow M, Smith J. Early onset scoliosis consensus statement, SRS Growing Spine Committee, 2015. Spine Deformity. 2015;3(2):107.
- Rhodes L, Nash C, Moisan A, Scott DC, Barkoh K, Warner WC Jr, Sawyer JR, Kelly DM.Does preoperative orientation and education alleviate anxiety in posterior spinal fusion patients? A prospective, randomized study. J Pediatr Orthop. 2015 Apr-May;35(3):276-9.
- Novais EN, Hill MK, Carry PM, Heare TC, Sink EL. Modified Dunn procedure is superior to in situ pinning for short-term clinical and radiographic improvement in severe stable SCFE. Clin Orthop Relat Res. 2015 Jun;473(6):2108-17. Epub 2014 Dec 12
- Hailer YD, Nilsson O. Legg-Calvé-Perthes disease and the risk of ADHD, depression, and mortality. Acta Orthop. 2014 Sep;85(5):501-5. Epub 2014 Jul 18.
- Jayanthi NA, LaBella CR, Fischer D, Pasulka J, Dugas L. Sports-specialized intensive training and the risk of injury in young athletes: a clinical case-control study. Am J Sports Med. 2015 Apr;43(4):794-801. Epub 2015 Feb 2.
- Ramski DE, Kanj WW, Franklin CC, Baldwin KD, Ganley TJ. Anterior cruciate ligament tears in children and adolescents: a meta-analysis of nonoperative versus operative treatment. Am J Sports Med. 2014 Nov;42(11):2769-76. Epub 2013 Dec 4.
- Lee IH, Chung CY, Lee KM, Kwon SS, Moon SY, Jung KJ, Chung MK, Park MS. Incidence and risk factors of allograft bone failure after calcaneal lengthening. Clin Orthop Relat Res. 2015 May;473(5):1765-74. Epub 2014 Nov 14.
- Chong DY, Macwilliams BA, Hennessey TA, Teske N, Stevens PM. Prospective comparison of subtalar arthroereisis with lateral column lengthening for painful flatfeet. J Pediatr Orthop B. 2015 Jul;24(4):345-53.
On Monday, Nov. 23, 2015 at 8:00 PM EDT, JBJS will host a one-hour webinar focused on managing pediatric supracondylar humeral fractures.
Because supracondylar humeral fractures present with various degrees of displacement and concomitant injuries may be difficult to assess precisely, there is no single, accepted protocol for managing this condition.This complimentary webinar, moderated by JBJS Deputy Editor for Pediatrics Paul Sponseller, MD, will examine the efficacy of different approaches to supracondylar humeral fractures—and their neurovascular consequences.
Brain Scannell, MD and Christine Ho, MD, will explore pulseless supracondylar humeral fractures by presenting findings from separate but related studies published in JBJS in 2013. In addition, John Flynn, MD, will present findings from his 2014 JBJS study, which investigated isolated anterior interosseous nerve (AIN) injuries accompanying supracondylar humeral fractures.Commentary from pediatric orthopaedist Donald Bae, MD will complement the author presentations, and the webinar will conclude with a live audience Q&A session.
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from Level I and II studies cited in the February 18, 2015 Specialty Update on pediatric orthopaedics:
–The landmark BrAIST study found that bracing helps prevent adolescent idiopathic scoliosis curves from progressing to a surgical range (≥50°), with a number needed to treat of 3. (See related OrthoBuzz article.)
–A randomized trial comparing the SpineCor brace to rigid bracing for correction of scoliosis found that the rate of curve progression was significantly higher in the SpineCor group.
–A study on the role of steroids in patients with Duchenne muscular dystrophy found that glucocorticoid therapy decreased the need for spinal surgery to treat scoliosis.
–A randomized trial among patients 4 to 12 years of age with a distal radial or distal both-bone fracture found that the use of a double-sugar-tong splint for immediate post-reduction immobilization was at least as effective as the use of a plaster long arm cast.
–A randomized controlled trial of 61 patients from 5 to 12 years old who had a supracondylar humeral fracture found no functional or elbow-motion benefits associated with hospital-based physical therapy after short-term casting.
Foot and Ankle
–A randomized trial of 27 children less than 9 months of age who had resistant metatarsus adductus found that a group receiving orthotic treatment had greater improvement in footprint heel bisector measurements than those receiving serial casting. The orthotic program required more active parental participation but was about half the cost of casting.
–A randomized study of children under 3 months of age with idiopathic clubfoot who were treated with the Ponseti method found that the failure rates and treatment times were significantly higher in a below-the-knee casting group than in an above-the-knee casting group.